Review Us Now

(562) 274-7771 (Whittier)

(562) 865-0569 (Artesia)

(626) 400-5040 (Irwindale) - New Location!

Review Us Now

(562) 274-7771 (Whittier)

(562) 865-0569 (Artesia)

(626) 400-5040 (Irwindale) - New Location!

Home

Artesia Patient Intake Form

Artesia Patient Intake Form

How did you hear about us?

Internet Insurance Met Doctor Referral

Name

First Name*

Last Name*

General Info.

Patient Name

First Name

Last Name

Today's Date

Home Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Home Phone

Cell Phone

Email Address *

DOB

ID #

SSN #

Emergency Contact

First name

Last Name

Relationship to Patient

Home Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Home Phone

Cell Phone

Employment Info

Student Other

If other

Employer/School

Work Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Work Phone

Work Email

Health Insurance Info

Name of Insured

First Name

Last Name

If Other

Insurance Provider

PPO HMO Medicare Other

If other

ID #

Policy #

Group #

Insurance Phone # (on back of card)

Primary Physician

First Name

Last Name

Phone Number

Party Responsible for account

Above Patient is Responsible. OR Above Patient is Responsible. OR

Name

First Name

Last Name

Relationship to Patient

Home Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Home Phone

Cell Phone

DOB

ID #

SSN#

Medical Information

Age

Height: feet

Inches

Weight (lbs)

Date of Last Medical Exam

Doctor's Name

First Name

Last Name

Recent medical procedures

Date

Results

ALL Prescribed Medications

ALL Over-the-Counter Medications

Known congenital (from birth) factors that relate to your condition?

Yes No

If Yes

Previous illnesses/complications from previous injuries?

Yes No

If Yes

Hospitalizations or surgeries? Including childhood?

Yes No

If Yes

Is there any chance you may be pregnant?

Yes No

If yes, # of weeks

Cancer/tumor/lump

Detail

Blood disease

Yes No

Detail

Stroke - date

Yes No

Detail

Social History - Check ALL that apply to you

Daily work/home habits

Prolonged sitting/standing Heavy lifting Poor posture Other

If other

Daily Work Habits Sports/activities/hobbies

Family Medical History

1. Family Member

Age